University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In a patient with ADHD, is behavioral therapy as effective as medical therapy in controlling ADHD symptoms?

Clinical Bottom Lines

1. Therapy of any type resulted in significant improvement in symptoms.
2. Therapy with medication alone and with combination of medication plus behavioral therapy resulted in the greatest improvement in ADHD symptoms.
3. Combined treatment proved superior in controlling oppositional/aggressive symptoms, internalizing symptoms, teacher rated-social skills, parent-child relations, and reading achievement.
4. Significantly lower doses of medication were required with combination therapy than with medication therapy alone.

Summary of Key Evidence

1. 579 children with ADHD aged 7 to 9.9 years were randomized to receive medication management consisting of methylphenidate, intensive behavioral treatment, a combination of both, or standard community care over 14 months.¹
2. Medication management began with methylphenidate TID dosing titrated to maximal effect through monthly visits with pharmacotherapists.
3. Behavioral treatment included parent training in both group and individual weekly sessions tapered over time, child-focused treatment with an 8-week summer program, and school-based intervention with bi-weekly teacher consultation and paraprofessional aides working with the child.
4. In family report of side effects in combined treatment and medication management subjects, 35.9% reported none, 49.8% reported mild side effects, 11.4% moderate, and 2.9% severe.

Additional Comments

• ADHD affects 3-5% of school-aged children and accounts for up to 50% of child referrals to mental health services.
• Treatment satisfaction scores for combined treatment and behavioral treatment were significantly higher than for medication management alone.
• Once daily Concerta treatment may be as effective as TID methylphenidate dosing.²
• Studies of long-term effects of stimulant medication are still lacking.
  

Citation

1. Anonymous. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Archives of General Psychiatry 1999;56:1073-86.
2. Pelham WE, Gnagy EM, Burrows-Maclean L, et al. Once-a-day Concerta methylphenidate versus three-times-daily methylphenidate in laboratory and natural settings. Pediatrics 2001;107:E105.

CAT Author: Elisa Picken, MD

CAT Appraisers: Jonathan Fliegel, MD

Date appraised: April 20, 2005